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MONTANA DEPARTMENT OF PUBLIC HEALTH & HUMAN SERVICES
CONSUMER COMPLAINT FORM -- PROCESSED FOOD/BEVERAGE
This form is for use by County Health Departments for reporting processed food complaints to DPHHS
for possible referral to FDA or USDA
Date__________Form completed by___________________________Phone: ( )____________
Product Name________________________________________Size________________________
Manufacturer & Address___________________________________________________________
Code or Indentification #___________________________________________________________
Use-by date or code______________________________________________________________
Where Purchased____________________Address_______________________MT___Zip______
Has the Retail Source Been Contacted?__________Retail Phone__________________________
Retail Person Contacted___________________________Time and Date Purchased___________
Consumer____________________________________Address____________________________
City/State/Zip________________________________________Email_______________________
Day Phone ( )___________________Work Phone ( )______________Other_____________
Where & When Consumed or Discovered:_____________________________________________
_______________________________________________________________________________
Complaint Explanation:____________________________________________________________
_______________________________________________________________________________
Amount of product left_____________________________________Where___________________
Sample Obtained & Submitted to Laboratory?__________________________________________
Has Illness/Injury Occurred?____________________(If illness, attach additional information/food history....)
Doctor's Name and Address________________________________________________________
Hospital/Location/Phone/Dates______________________________________________________
Findings & Disposition:____________________________________________________________
________________________________________________________________Continue On Back.
(Enter information in above spaces and fax to the 24 hour Disease Reporting Hotline at 1-800-616-7460
or fax to the Montana Food & Drug Program 406-444-4135)
Follow Up:______________________________________________________________________
_______________________________________________________________________________
Food, Drug & Cosmetic Program/Food & Consumer Safety Section sstrom@state.mt.us
Cogswell Bldg C-317, Helena, Montana 59620/Phone (406) 444-2408 Fax (406) 444-4135
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